Prof. K.A.P. Siddhisena

Department of DemographyUniversity of Colombo, Sri Lanka

Presentation at the Department of International HealthJohns Hopkins University

Baltimore, Maryland6.12.2016.

Population aging and health care needs of the elderly people in Sri Lanka: An overview

Population aging represents one of the most significant phenomena indeveloping world, especially in South and South East Asia in the newmillennium.

In the developing world, the population aged 60 and over is projected totriple from 473 million in 2009 to 1.6 billion in 2050 (UNDESA, 2009)

Owing to substantial decline in fertility and spectacular decline inmortality, and pronounced gain in longevity, most Asian countries,especially in South Asia and South East Asian countries are aging at anever increasing pace (Mujahid and Siddhisena, 2009; Gavin Jones, 2013)..

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1.1 Introduction

1.5 Definition of ageing and elderly population In Biological aspect it defines as “aging is a process of

progressive overall deterioration of different parts of the body thatstarts after a particular age” (Bagchi, 2006).

According to Gorman (2007) aging process is a biological realitywhich has its own dynamic, largely beyond human control,

In social and demographic aspect, population aging refers to theprocess of increase in the proportion of the elderly (older) personsin the total population.

Due to different connotations of the aging population in differentcountries, the definition of ageing itself is arbitrary. Developingcountries 60+ vs developed 65+.

In Sri Lanka, aged 60 and over is considered the demarcation age inidentifying the elderly population, since the most commonmandatory retirement age in the public, private and the corporatesectors falls between ages 55 and 60 respectively, with an extensionperhaps of up to 5 years (Siddhisena, 2004).

Sri Lanka is continuously experiencing one of the fastest agingpopulations in the developing world due to its speedy demographictransition. The proportion of the population over 60 years hasincreased from 5.3 in 1953 to 12.2% in 2012 and it will further riseto one quarter of Sri Lanka’s population by 2030.

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Introduction cont…..

Definition of Aging in the Case of Sri Lanka

60-69 years - Physically active,Young Old Mentally alert and

economically productive

70-79 years -Old-Old

Over 80 years - Often physically frail with Oldest Old different impairments and

morbidity12/7/2016 5

Elderly Population can be further divided

Sri Lanka has the highest proportion of elderly persons (60+ and 80+) and will be the most “aged” country in South Asia in from 2000 to 2050 (See Table).

The proportion of the population older than 60 (or 80) years in Sri Lanka was much higher – almost double – than in any other country in the region in 2000, and is projected to still be so over the next few decades.

It is expected that nearly one of every 5 Sri Lankans will be elderly. In contrast, the corresponding figures for other countries in the region are expected to about one in 18 people in Afghanistan, about one in 9 people in India in 2025.

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Population Aging in Sri Lanka in the Context of South Asia

`

Country Population 60+(%)

2015 2030 2050

Median Age(years)

2015 2030 2050

Afghanistan `4.0 5.1 9.0 17.5 22.5 29.8Bangladesh 7.0 11.5 21.5 25.6 31.5 39.6Bhutan 7.4 11.6 24.5 26.7 33.7 41.9India 8.9 12.5 19.4 26.1 31.2 37.3Nepal 8.6 10.8 17.9 23.1 29.3 38.9Pakistan 6.6 8.4 12.9 22.5 25.5 30.9Sri Lanka 13.9 21.5* 28.6 32.3 37.6 42.5

Sources: UNDESA, World Population Prospects 2015; UN, World Population Ageing, 2015; *Estimated from Dept. of Census and Statistics

Population Aging in Sri Lanka in the Context of South Asia

Country Population 80+(%) in older population

2000 2025 2050

Afghanistan ` 4.7 5.5 5.8Bangladesh 6.7 7.3 11.2Bhutan 7.9 9.8 11.5India 8.2 10.8 15.3Nepal 6.9 7.9 10.2Pakistan 8.0 9.5 12.1Sri Lanka 12.0 15.0 20.9

Sources: UNDESA, 2012.

Oldest in the Elderly Population in South Asian Countries

• Sri Lanka experienced an increasing trend of elderly population since 1950s, primarily due to substantial fertility decline, and secondarily to a spectacular decline in mortality at all ages, and pronounced gain in longevity that commenced in the early 1950s,

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Determinants of Rapid Ageing in Sri Lanka

Crude Birth Rates & Crude Death Rates, 1950-2015

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Life Expectancy at Birth, Sri Lanka by Sex- 1921-2013

Year Male Femal DifferenceMale-Female

1920-1922 32.7 30.7 -2.01945-1947 46.8 44.7 -2.11952-1954 57.6 55.5 -2.11962-1964 63.3 63.7 0.41970-1972 64.0 66.9 2.91980-1982 67.7 72.1 4.02000-2002 68.8 77.2 8.42011-2013 72.0 78.6 6.6

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• Age structural changes depict in age pyramids (see pyramids 1971-2030 and further predicted years).

• The paradox shift from younger population to older population (see figure)

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75+70-7465-6960-6455-5950-5445-4940-4435-3930-3425-2920-2415-1910-14

5-90-4

01234567

0 1 2 3 4 5 6 7

75+70-7465-6960-6455-5950-5445-4940-4435-3930-3425-2920-2415-1910-14

5-90-4

01234567

0 1 2 3 4 5 6 7

75+70-7465-6960-6455-5950-5445-4940-4435-3930-3425-2920-2415-1910-14

5-90-4

01234567

0 1 2 3 4 5 6 7

Male Female

Male FemaleMale Female

1981 2001

2021Percent Percent

Percent

Population Age Pyramids 1981, 2001 and 2021Age Age

Age

15

05

1015202530354045

1946 1953 1963 1971 1981 1991 2001 2011 2021 2031

Perc

enta

ge

Year

Pop. <15 Pop. 60+

Population below 15 and 60 and above Sri Lanka, 1946-2031

Period

Fertility Projection (TFR)

___________________

Standard High Low

Mortality projection

(standard) e0

Male Female1991-1996 2.3 2.4 2.3 69.5 74.21996-2001 2.2 2.3 2.0 70.7 75.42001-2006 2.1 2.2 1.8 71.7 76.42006-2011 2.0 2.1 1.6 72.7 77.42011-2016 1.9 2.1 1.5 73.5 78.42016-2021 1.8 2.1 1.5 74.3 79.22021-2026 1.7 2.1 1.5 75.1 80.02026-2031 1.7 2.1 1.5 75.6 80.8

Source: De Silva, 1993, Population and Labour force Projection, Department of Census and Statistics16

Projected fertility and Mortality levels in Sri Lanka -1991-2031

- 1 000 - 500 0 500 1 000

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-79

80+

Population (Thousands)

Age

1950

Male Female

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-1500 -1000 -500 0 500 1000 1500

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-79

80+

Population (Thousands)

Age

2000

Male Female

-1500 -1000 -500 0 500 1000 1500

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-79

80+

Population (Thousands)

Age

2010

-1000 -500 0 500 1000

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-79

80+

Population (Thousands)

Age

2050

Male Female

Source: Own computations based on world population prospects by the United Nations, the 2010 revision.

population of Sri Lanka by age and sex , 1950-2050

Year Total population(,000) Percentage age 60 + TotalAged 60+ Median age

1946 6,657 5.4 21.3

1953 8,098 5.4 2.80 2.81 2.8

1963 10,582 6.0 2.68 3.51 19.4

1971 12,690 6.3 2.27 3.27 19.7

1981 14,847 6.6 1.57 2.12 21.4

1991 17,259 8.1 1.51 3.50 25.0

2001 19,015 10.0 0.97 3.09 28.8

2011 20,873 12.0 0.93 3.63 32.5

2021 22,324 17.8 0.67 3.72 36.3

2031 23,129 21.9 0.35 2.40 39.5

Average annual grow rate (%)

A Closer Look at the Demography of Ageing in Sri LankaTotal population, percentage of population aged 60+ years and

growth rate, 1946-2031

Source : Department of Census and Statistics ,Census Reports 1946-1981

Category2010 2025 2050

Population 60+ (thousands)Population 70+ (thousands)Population 80+ (thousands)

2,508997290

4.3301,985

524

6,0443,2031,421

% Population 60+ % Population 70+%Population 80+

12.34.91.4

19.79.02.4

27.814.86.5

Ageing Index 50.6 92.2 159.6Potential Support Ratio 8.8 4.7 2.9Daughter Care Potential Ratio 2.8 1.6 1.1

Source: Dept. of Census & Statistics, UNDESA, 2010

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Population beyond 60 and Population Ageing Indices , 2010-2050

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Notes: Child dependency = Number of persons aged 0-14 per 100 persons aged 15-59Elderly dependency = Number of persons aged 60+ per 100 persons aged 15-59Total dependency = Child dependency +Elderly dependency

Source: Data for the Census Years are from census Reports and for 1994 from Demographic survey, data for 1991 and 2001-2031 from De Silva,(1993)

Trends of dependency ratios and indices of ageing, Sri Lanka, 1946-2031

• Ageing population in Sri Lanka took about 52 years to double from 5.4 in 1946 to 10.8 in 2002.

• However the second doubling of ageing in Sri Lanka will take place sooner than first doubling as by taking 23 years due to expected more rapid pace of ageing since 2000 (Siddhisena, 2004).

• It is noteworthy that when the whole period 1981-2031 is considered, a more than tripling of ageing (ages 60+) is projected .

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Tempo of Ageing

Speed of Ageing of 60+ Population in Selected Asian and Developed Economies by 2050

Slow Moderate Rapid

South and South -West Asia• Afghanistan• Bangladesh• Nepal• Pakistan

• Bhutan• India• Iran• Maldives• Turkey

• Sri Lanka

South-East Asia• Cambodia• Lao People’s Democratic Republic• Timor-Leste• Philippines

• Malaysia• Myanmar• Indonesia• Viet Nam• Brunei Derussalam

• Thailand• Singapor

Developed Economies• Australia• New Zeeland• Japan• USA

Note: Slow - percentage of 60+ population in 2050 is less than 20 per cent.Moderate - percentage of 60+ population in 2050 is between 20 to 25 percent.Rapid - percentage of 60+ population in 2050 is greater than 25 per cent. 22

• Among elders, female numbers are higher than males due to increase in life expectancy.

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Sex Ratio 2010 2025 2050

% Population 60+ 83.7 77.9 75.4

% Population 70+ 74.8 69.2 60.7

% Population 80+ 67.7 56.3 48.6

Feminization in Ageing in Sri Lanka

Universally, Elderly people tend to be in poorer healthand need more medical services than the young. Theincidence of frailty and physical dependence increasessubstantially among elderly aged 80+.

An increase in the percentage of elderly people result achange in the volume of services needed, and the type ofservices. The pattern and causes of their illness aredifferent as well (e.g. Alzheimer and dementia-needspecial care and geriatrics treatment-high cost).

The health system will need to move from the provision ofmostly acute treatments for infectious disease to managingchronic treatment for non-communicable disease due tophysical chnges.

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Health Care Need of Elderly People

Diseases due to physical changes of elderly Chronic Diseases Ischemic Heart Diseases Stroke Arthritis (8% in 2014)Hypertension (27.3% in 2014)Diabetes Mellitus (prevalence 18% in 2014) Chronic obstructive airways diseases Vision and hearing impairmentCancerPoor nutritionFrailty –disability/bed ridden/functional capacitieCosmetic changes

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Contd.

Mental diseases DepressionMemory impairment –Dementia, AlzheimerLoss of self esteemEmpty nest syndrome – feel lonelySense of burden to family and society

• The above diseases create a demand for intensive diagnostic test, long-term hospitalization and better treatment and rehabilitation which involve hravy nvestment,

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Contd. health Care need

Recent survey (2014) found that 55.2 percentof total elderly (60+ years) suffers from atleast one chronic illness. This prevalence bysex- 51.9 percent of elderly males and 57.8percent of elderly females. This is wide gap-total pop. about 1 in 5 person (18%).

Due to the above various chronic diseasesand morbidity transition in Sri Lank, elderlyneeds health care services. Health caresystem in Sri Lanka cater the needs.

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Feature of Health care system

The overall health care system is composed ofparallel public and private sectors.

The comprehensive public health care system isfinanced and operated by the Ministry of Health inColombo and eight provincial Department of Health.The Health Ministry and the Provincial HealthServices provide a wide range of preventive, curativeand rehabilitative healthcare. Government spends3.2% of GDP.

Vertical healthcare programmes have been deliveredby grass root health workers, public health midwifesand public health inspectors.

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Contd.

• In addition, The health system in Sri Lanka isenriched by a mix of indigenous, allopathic,Ayurveda, Unani and other systems of medicine.Rural elderly seeks these services more than urbanelderly.

• Public sector provides more than 95 percent of inpatient care.

• Since 1960s private sector is prominent and focuses mainly on outpatient care and run private hospitals in major cities.

• The country has an extensive network of healthcare institutions

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Policy options As Currently, there is an increased impact of non-communicable and

lifestyle-related diseases (NCD) on the health status of the elderly the existing vertical programmes are insufficient and therefore to meet new challenges a range of geriatric and primary health care needed.Geriatric wards should be established at least in most generl hospitals,

base hospitals and peripheral hospitals. Geriatric education programmes should be promoted at the university

level and at training Institutes (like nursing Institute, Ayurveda Institutes) As it is difficult to separate health expenditure for the elderly only from

generl health expenditure budget, it is better to allocate separate budget for geriatric and primary health care for elderly. Health insurance schemes for elderly should be promoted. Greater attention should be given to subsidies for the prevailing high

costs of health care provision and treatment, suitably adjusting them for inflation, so as to improve the health conditions of the elderly.

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Myers G.C., 1990, Demography of aging, in Binstock R. and George L. (eds.), Handbook of Aging and the Social Sciences, 3rd edition, New York, Van Nostrand Reinhold.

Siddhisena K.A.P., 2004, Demography of Ageing in Sri Lanka,, Population Association of Sri Lanka and UNFPA, Ageing Population in Sri Lanka: Issues and Future Prospects, Colombo, PASL and UNFPA : Chap 1:7-43.

Siddhisena K.A.P. and Ratnayake K., 1998, Aging population and elderly care in Sri Lanka, Sri Lanka Journal of Population studies, 1(1): 35-55.

UNDESA , 2014, World population Ageing 2013, New York, United Nations Department of Economic and Social Affairs.

United Nations, 2015, World Population Prospects-The 2015 Revision, New York, United Nations.

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The selected references have been used in this presentation

THANK YOU!

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